Text messaging and brief phone calls for weight loss in overweight and obese English- and Spanish-speaking adults: A 1-year, parallel-group, randomized controlled trial.

BACKGROUND: Weight loss interventions based solely on text messaging (short message service [SMS]) have been shown to be modestly effective for short periods of time and in some populations, but limited evidence is available for positive longer-term outcomes and for efficacy in Hispanic populations. Also, little is known about the comparative efficacy of weight loss interventions that use SMS coupled with brief, technology-mediated contact with health coaches, an important issue when considering the scalability and cost of interventions. We examined the efficacy of a 1-year intervention designed to reduce weight among overweight and obese English- and Spanish-speaking adults via SMS alone (ConTxt) or in combination with brief, monthly health-coaching calls. ConTxt offered 2-4 SMS/day that were personalized, tailored, and interactive. Content was theory- and evidence-based and focused on reducing energy intake and increasing energy expenditure. Monthly health-coaching calls (5-10 minutes' duration) focused on goal-setting, identifying barriers to achieving goals, and self-monitoring. METHODS AND FINDINGS: English- and Spanish-speaking adults were recruited from October 2011 to March 2013. A total of 298 overweight (body mass index [BMI] 27.0 to 39.9 kg/m2) adults (aged 21-60 years; 77% female; 41% Hispanic; 21% primarily Spanish speaking; 44% college graduates or higher; 22% unemployed) were randomly assigned (1:1) to receive either ConTxt only (n = 101), ConTxt plus health-coaching calls (n = 96), or standard print materials on weight reduction (control group, n = 101). We used computer-based permuted-block randomization with block sizes of three or six, stratified by sex and Spanish-speaking status. Participants, study staff, and investigators were masked until the intervention was assigned. The primary outcome was objectively measured percent of weight loss from baseline at 12 months. Differences between groups were evaluated using linear mixed-effects regression within an intention-to-treat framework. A total of 261 (87.2%) and 253 (84.9%) participants completed 6- and 12-month visits, respectively. Loss to follow-up did not differ by study group. Mean (95% confidence intervals [CIs]) percent weight loss at 12 months was -0.61 (-1.99 to 0.77) in the control group, -1.68 (-3.08 to -0.27) in ConTxt only, and -3.63 (-5.05 to -2.81) in ConTxt plus health-coaching calls. At 12 months, mean (95% CI) percent weight loss, adjusted for baseline BMI, was significantly different between ConTxt plus health-coaching calls and the control group (-3.0 [-4.99 to -1.04], p = 0.003) but not between the ConTxt-only and the control group (-1.07 [-3.05 to 0.92], p = 0.291). Differences between ConTxt plus health-coaching calls and ConTxt only were not significant (-1.95 [-3.96 to 0.06], p = 0.057). These findings were consistent across other weight-related secondary outcomes, including changes in absolute weight, BMI, and percent body fat at 12 months. Exploratory subgroup analyses suggested that Spanish speakers responded more favorably to ConTxt plus health-coaching calls than English speakers (Spanish contrast: -7.90 [-11.94 to -3.86], p < 0.001; English contrast: -1.82 [-4.03 to 0.39], p = 0.107). Limitations include the unblinded delivery of the intervention and recruitment of a predominantly female sample from a single site. CONCLUSIONS: A 1-year intervention that delivered theory- and evidence-based weight loss content via daily personalized, tailored, and interactive SMS was most effective when combined with brief, monthly phone calls. TRIAL REGISTRATION: ClinicalTrials.gov NCT01171586.

Low-Cost Air Quality Monitoring Tools: From Research to Practice (A Workshop Summary).

In May 2017, a two-day workshop was held in Los Angeles (California, U.S.A.) to gather practitioners who work with low-cost sensors used to make air quality measurements. The community of practice included individuals from academia, industry, non-profit groups, community-based organizations, and regulatory agencies. The group gathered to share knowledge developed from a variety of pilot projects in hopes of advancing the collective knowledge about how best to use low-cost air quality sensors. Panel discussion topics included: (1) best practices for deployment and calibration of low-cost sensor systems, (2) data standardization efforts and database design, (3) advances in sensor calibration, data management, and data analysis and visualization, and (4) lessons learned from research/community partnerships to encourage purposeful use of sensors and create change/action. Panel discussions summarized knowledge advances and project successes while also highlighting the questions, unresolved issues, and technological limitations that still remain within the low-cost air quality sensor arena.

Face-to-Face and Online Networks: College Students' Experiences in a Weight-Loss Trial.

This study aimed to understand how college students participating in a 2-year randomized controlled trial (Project SMART: Social and Mobile Approach to Reduce Weight; N = 404) engaged their social networks and used social and mobile technologies to try and lose weight. Participants in the present study (n = 20 treatment, n = 18 control) were approached after a measurement visit and administered semi-structured interviews. Interviews were analyzed using principles from grounded theory. Treatment group participants appreciated the timely support provided by the study and the integration of content across multiple technologies. Participants in both groups reported using non-study-designed apps to help them lose weight, and many participants knew one another outside of the study. Individuals talked about weight-loss goals with their friends face to face and felt accountable to follow through with their intentions. Although seeing others' success online motivated many, there was a range of perceived acceptability in talking about personal health-related information on social media. The findings from this qualitative study can inform intervention trials using social and mobile technologies to promote weight loss. For example, weight-loss trials should measure participants' use of direct-to-consumer technologies and interconnectivity so that treatment effects can be isolated and cross-contamination accounted for.

Using social and mobile tools for weight loss in overweight and obese young adults (Project SMART): a 2 year, parallel-group, randomised, controlled trial.

BACKGROUND: Few weight loss interventions are evaluated for longer than a year, and even fewer employ social and mobile technologies commonly used among young adults. We assessed the efficacy of a 2 year, theory-based, weight loss intervention that was remotely and adaptively delivered via integrated user experiences with Facebook, mobile apps, text messaging, emails, a website, and technology-mediated communication with a health coach (the SMART intervention). METHODS: In this parallel-group, randomised, controlled trial, we enrolled overweight or obese college students (aged 18-35 years) from three universities in San Diego, CA, USA. Participants were randomly assigned (1:1) to receive either the intervention (SMART intervention group) or general information about health and wellness (control group). We used computer-based permuted-block randomisation with block sizes of four, stratified by sex, ethnicity, and college. Participants, study staff, and investigators were masked until the intervention was assigned. The primary outcome was objectively measured weight in kg at 24 months. Differences between groups were evaluated using linear mixed-effects regression within an intention-to-treat framework. Objectively measured weight at 6, 12, and 18 months was included as a secondary outcome. The trial is registered with ClinicalTrials.gov, number NCT01200459. FINDINGS: Between May 18, 2011, and May 17, 2012, 404 individuals were randomly assigned to the intervention (n=202) or control (n=202). Participants' mean (SD) age was 22·7 (3·8) years. 284 (70%) participants were female and 125 (31%) were Hispanic. Mean (SD) body-mass index at baseline was 29·0 (2·8) kg/m(2). At 24 months, weight was assessed in 341 (84%) participants, but all 404 were included in analyses. Weight, adjusted for sex, ethnicity, and college, was not significantly different between the groups at 24 months (-0·79 kg [95% CI -2·02 to 0·43], p=0·204). However, weight was significantly less in the intervention group compared with the control group at 6 months (-1·33 kg [95% CI -2·36 to -0·30], p=0·011) and 12 months (-1·33 kg [-2·30 to -0·35], p=0·008), but not 18 months (-0·67 kg [95% CI -1·69 to 0·35], p=0·200). One serious adverse event in the intervention group (gallstones) could be attributable to rapid and excessive weight loss. INTERPRETATION: Social and mobile technologies did not facilitate sustained reductions in weight among young adults, although these approaches might facilitate limited short-term weight loss. FUNDING: The National Heart, Lung, and Blood Institute of the National Institutes of Health (U01 HL096715).

Clinical trial management of participant recruitment, enrollment, engagement, and retention in the SMART study using a Marketing and Information Technology (MARKIT) model.

Advances in information technology and near ubiquity of the Internet have spawned novel modes of communication and unprecedented insights into human behavior via the digital footprint. Health behavior randomized controlled trials (RCTs), especially technology-based, can leverage these advances to improve the overall clinical trials management process and benefit from improvements at every stage, from recruitment and enrollment to engagement and retention. In this paper, we report the results for recruitment and retention of participants in the SMART study and introduce a new model for clinical trials management that is a result of interdisciplinary team science. The MARKIT model brings together best practices from information technology, marketing, and clinical research into a single framework to maximize efforts for recruitment, enrollment, engagement, and retention of participants into a RCT. These practices may have contributed to the study's on-time recruitment that was within budget, 86% retention at 24 months, and a minimum of 57% engagement with the intervention over the 2-year RCT. Use of technology in combination with marketing practices may enable investigators to reach a larger and more diverse community of participants to take part in technology-based clinical trials, help maximize limited resources, and lead to more cost-effective and efficient clinical trial management of study participants as modes of communication evolve among the target population of participants.

Click "like" to change your behavior: a mixed methods study of college students' exposure to and engagement with Facebook content designed for weight loss.

BACKGROUND: Overweight or obesity is prevalent among college students and many gain weight during this time. Traditional face-to-face weight loss interventions have not worked well in this population. Facebook is an attractive tool for delivering weight loss interventions for college students because of its popularity, potential to deliver strategies found in successful weight loss interventions, and ability to support ongoing adaptation of intervention content. OBJECTIVE: The objective of this study was to describe participant exposure to a Facebook page designed to deliver content to overweight/obese college students in a weight loss randomized controlled trial (N=404) and examine participant engagement with behavior change campaigns for weight loss delivered via Facebook. METHODS: The basis of the intervention campaign model were 5 self-regulatory techniques: intention formation, action planning, feedback, goal review, and self-monitoring. Participants were encouraged to engage their existing social network to meet their weight loss goals. A health coach moderated the page and modified content based on usage patterns and user feedback. Quantitative analyses were conducted at the Facebook post- and participant-level of analysis. Participant engagement was quantified by Facebook post type (eg, status update) and interaction (eg, like) and stratified by weight loss campaign (sequenced vs nonsequenced). A subset of participants were interviewed to evaluate the presence of passive online engagement or "lurking." RESULTS: The health coach posted 1816 unique messages to the study's Facebook page over 21 months, averaging 3.45 posts per day (SD 1.96, range 1-13). In all, 72.96% (1325/1816) of the posts were interacted with at least once (eg, liked). Of these, approximately 24.75% (328/1325) had 1-2 interactions, 23.39% (310/1325) had 3-5 interactions, 25.13% (333/1325) had 6-8 interactions, and 41 posts had 20 or more interactions (3.09%, 41/1325). There was significant variability among quantifiable (ie, visible) engagement. Of 199 participants in the final intervention sample, 32 (16.1%) were highly active users and 62 (31.2%) never visibly engaged with the intervention on Facebook. Polls were the most popular type of post followed by photos, with 97.5% (79/81) and 80.3% (386/481) interacted with at least once. Participants visibly engaged less with posts over time (partial r=-.33; P<.001). Approximately 40% of the participants interviewed (12/29, 41%) reported passively engaging with the Facebook posts by reading but not visibly interacting with them. CONCLUSIONS: Facebook can be used to remotely deliver weight loss intervention content to college students with the help of a health coach who can iteratively tailor content and interact with participants. However, visible engagement with the study's Facebook page was highly variable and declined over time. Whether the level of observed engagement is meaningful in terms of influencing changes in weight behaviors and outcomes will be evaluated at the completion of the overall study.

Feasibility and effectiveness of an automated bilingual text message intervention for weight loss: pilot study.

BACKGROUND: Little is known about the feasibility and acceptability of tailored text message based weight loss programs for English and Spanish-language speakers. OBJECTIVE: This pilot study evaluated the feasibility, acceptability, and estimated impact of a tailored text message based weight loss program for English and Spanish-language speakers. The purpose of this pilot study was to inform the development of a full-scale randomized trial. METHODS: There were 20 overweight or obese participants (mean age 40.10, SD 8.05; 8/20, 40% male; 9/20, 45% Spanish-speakers) that were recruited in San Diego, California, from March to May 2011 and evaluated in a one-group pre/post clinical trial. For 8 weeks, participants received and responded to 3-5 text messages daily sent from a fully automated text messaging system. They also received printed weight loss materials and brief 10-15 minute weekly counseling calls. To estimate the impact of the program, the primary outcome was weight (kg) measured during face-to-face measurement visits by trained research staff. Pre and post differences in weight were analyzed with a one-way repeated measures analysis of variance. Differences by language preference at both time points were analyzed with t tests. Body mass index and weight management behaviors also were examined. Feasibility and acceptability were determined by recruitment success, adherence (ie, percentage of replies to interactive text messages and attrition), and participant satisfaction. RESULTS: Participants who completed the final assessment (N=18) decreased body weight by 1.85 kg (F1,17=10.80, P=.004, CI∆ 0.66-3.03, η(2)=0.39). At both time points, there were no differences in weight by language preference. Participants responded to 88.04% (986/1120) of interactive text messages, attrition rate was 10% (2/20), and 94% (19/20) of participants reported satisfaction with the program. CONCLUSIONS: This fully automated text message based weight program was feasible with English and Spanish-speakers and may have promoted modest weight loss over an 8-week period. TRIAL REGISTRATION: Clinicaltrials.gov NCT01171586; http://clinicaltrials.gov/ct2/show/NCT01171586 (Archived by WebCite at http://www.webcitation.org/6Ksr6dl7n).

Achieving reliable communication in dynamic emergency responses.

Emergency responses require the coordination of first responders to assess the condition of victims, stabilize their condition, and transport them to hospitals based on the severity of their injuries. WIISARD is a system designed to facilitate the collection of medical information and its reliable dissemination during emergency responses. A key challenge in WIISARD is to deliver data with high reliability as first responders move and operate in a dynamic radio environment fraught with frequent network disconnections. The initial WIISARD system employed a client-server architecture and an ad-hoc routing protocol was used to exchange data. The system had low reliability when deployed during emergency drills. In this paper, we identify the underlying causes of unreliability and propose a novel peer-to-peer architecture that in combination with a gossip-based communication protocol achieves high reliability. Empirical studies show that compared to the initial WIISARD system, the redesigned system improves reliability by as much as 37% while reducing the number of transmitted packets by 23%.

Impact of wireless electronic medical record system on the quality of patient documentation by emergency field responders during a disaster mass-casualty exercise.

INTRODUCTION: The use of wireless, electronic, medical records and communications in the prehospital and disaster field is increasing. OBJECTIVE: This study examines the role of wireless, electronic, medical records and communications technologies on the quality of patient documentation by emergency field responders during a mass-casualty exercise. METHODS: A controlled, side-to-side comparison of the quality of the field responder patient documentation between responders utilizing National Institutes of Health-funded, wireless, electronic, field, medical record system prototype ("Wireless Internet Information System for medicAl Response to Disasters" or WIISARD) versus those utilizing conventional, paper-based methods during a mass-casualty field exercise. Medical data, including basic victim identification information, acuity status, triage information using Simple Triage and Rapid Treatment (START), decontamination status, and disposition, were collected for simulated patients from all paper and electronic logs used during the exercise. The data were compared for quality of documentation and record completeness comparing WIISARD-enabled field responders and those using conventional paper methods. Statistical analysis was performed with Fisher's Exact Testing of Proportions with differences and 95% confidence intervals reported. RESULTS: One hundred simulated disaster victim volunteers participated in the exercise, 50 assigned to WIISARD and 50 to the conventional pathway. Of those victims who completed the exercise and were transported to area hospitals, medical documentation of victim START components and triage acuity were significantly better for WIISARD compared to controls (overall acuity was documented for 100% vs 89.5%, respectively, difference = 10.5% [95%CI = 0.5-24.1%]). Similarly, tracking of decontamination status also was higher for the WIISARD group (decontamination status documented for 59.0% vs 0%, respectively, difference = 9.0% [95%CI = 40.9-72.0%]). Documentation of disposition and destination of victims was not different statistically (92.3% vs. 89.5%, respectively, difference = 2.8% [95%CI = -11.3-17.3%]). CONCLUSIONS: In a simulated, mass-casualty field exercise, documentation and tracking of victim status including acuity was significantly improved when using a wireless, field electronic medical record system compared to the use of conventional paper methods.

A text message-based intervention for weight loss: randomized controlled trial.

BACKGROUND: To our knowledge, no studies have evaluated whether weight loss can be promoted in overweight adults through the use of an intervention that is largely based on daily SMS (Short Message Service: text) and MMS (Multimedia Message Service: small picture) messages transmitted via mobile phones. OBJECTIVE: This paper describes the development and evaluation of a text message-based intervention designed to help individuals lose or maintain weight over 4 months. METHODS: The study was a randomized controlled trial, with participants being exposed to one of the following two conditions, lasting 16 weeks: (1) receipt of monthly printed materials about weight control; (2) an intervention that included personalized SMS and MMS messages sent two to five times daily, printed materials, and brief monthly phone calls from a health counselor. The primary outcome was weight at the end of the intervention. A mixed-model repeated-measures analysis compared the effect of the intervention group to the comparison group on weight status over the 4-month intervention period. Analysis of covariance (ANCOVA) models examined weight change between baseline and 4 months after adjusting for baseline weight, sex, and age. RESULTS: A total of 75 overweight men and women were randomized into one of the two groups, and 65 signed the consent form, completed the baseline questionnaire, and were included in the analysis. At the end of 4 months, the intervention group (n = 33) lost more weight than the comparison group (-1.97 kg difference, 95% CI -0.34 to -3.60 kg, P = .02) after adjusting for sex and age. Intervention participants' adjusted average weight loss was 2.88 kg (3.16%). At the end of the study, 22 of 24 (92%) intervention participants stated that they would recommend the intervention for weight control to friends and family. CONCLUSIONS: Text messages might prove to be a productive channel of communication to promote behaviors that support weight loss in overweight adults.

Field provider position tracking at mass gathering events.

WIISARD (Wireless Internet Information System for Medical Response to Disasters) utilizes wireless technology to improve medical care at mass casualty disasters. An important component of WIISARD is geolocation tracking of field personnel at the disaster site. Accurate, real-time information on personnel has the potential to improve resource utilization at the disaster site, as well as increase the safety of first responders caring for victims at a hazardous scene.

Data quality for situational awareness during mass-casualty events.

Incident Command systems often achieve situational awareness through manual paper-tracking systems. Such systems often produce high latencies and in-complete data, resulting in inefficient and ineffective resource deployment. WIISARD (Wireless Internet Information System for Medical Response in Disasters) collects much more data than a paper-based system, dramatically reducing latency while increasing the kinds and quality of information available to incident commanders. Yet, the introduction of IT into a disaster setting is not problem-free. Notably, system component failures can delay the delivery of data. The type and extent of a failure can have varying effects on the usefulness of information displays. We describe a small, coherent set of customizble information overlays to address this problem, and we discuss reactions to these displays by medical commanders.

Middleware for reliable mobile medical workflow support in disaster settings.

Mobile information technology can help first responders assist patients more quickly, reliably, and safely, while focusing resources on those most in need. Yet the disaster setting complicates reliable networked computing. The WIISARD client-server architecture provides mobile IT support for medical response in disasters. Cached remote objects (CROs) are shared via publish/subscribe, enabling disconnected operation when out of network range and ensuring data consistency across clients with rollback/replay. CROs also provide a flexible, familiar, and performant programming model for client programmers. A drill with the San Diego MMST showed that a basic client-server architecture, even with CRO's, is insufficient, because prolonged network failures-to be expected in disaster reponse-inhibit group work. We describe an extension of the CRO model to clusters of computers that supports group work during network failures.

A wireless first responder handheld device for rapid triage, patient assessment and documentation during mass casualty incidents.

Medical care at mass casualty incidents and disasters requires rapid patient triage and assessment, acute care and disposition often in the setting of overwhelming numbers of victims, limited time, and little resources. Current systems rely on a paper triage tag on which rescuers and medical providers mark the patient's triage status and record limited information on injuries and treatments administered in the field. In this manuscript, we describe the design, development and deployment of a wireless handheld device with an electronic medical record (EMR) for use by rescuers responding to mass casualty incidents (MCIs) and disasters. The components of this device, the WIISARD First Responder (WFR), includes a personal digital assistant (PDA) with 802.11 wireless transmission capabilities, microprocessor and non-volatile memory, and a unique EMR software that replicates the rapidity and ease of use of the standard paper triage tag. WFR also expands its functionality by recording real-time medical data electronically for simultaneous access by rescuers, mid-level providers and incident commanders on and off the disaster site. WFR is a part of the Wireless Information System for Medical Response in Disasters (WIISARD) architecture.

Tablet computing for disaster scene managers.

WIISARD utilizes wireless technology to improve the care of victims following a mass casualty disaster. The WIISARD Scene Manager device (WSM) is designed to enhance the collection and accessibility of real-time data on victims, ambulances and hospitals for disaster supervisors and managers. We recently deployed WSM during a large-scale disaster exercise. The WSM performed well logging and tracking victims and ambulances. Scene managers had access to data and utilized the WSM to coordinate patient care and disposition.

Situational awareness during mass-casualty events: command and control.

In existing Incident Command systems, situational awareness is achieved manually through paper tracking systems. Such systems often produce high latencies and incomplete data, resulting in inefficient and ineffective resource deployment. The WIISARD system collects much more data than a paper-based system, dramatically reducing latency while increasing the kinds and quality of information available to Incident Commanders. The WIISARD Command Center solves the problem of data over-load and uncertainty through the careful use of limited screen area and novel visualization techniques.

RealityFlythrough: enhancing situational awareness for medical response to disasters using ubiquitous video.

The first moments at a disaster scene are chaotic. The command center initially operates with little knowledge of hazards, geography and casualties, building up knowledge of the event slowly as information trickles in by voice radio channels. RealityFlythrough is a tele-presence system that stitches together live video feeds in real-time, using the principle of visual closure, to give command center personnel the illusion of being able to explore the scene interactively by moving smoothly between the video feeds. Using RealityFlythrough, medical, fire, law enforcement, hazardous materials, and engineering experts may be able to achieve situational awareness earlier, and better manage scarce resources. The RealityFlythrough system is composed of camera units with off-the-shelf GPS and orientation systems and a server/viewing station that offers access to images collected by the camera units in real time by position/orientation. In initial field testing using an experimental mesh 802.11 wireless network, two camera unit operators were able to create an interactive image of a simulated disaster scene in about five minutes.